Inspection Reports for
Riverside Health Care Center

The revisit survey was related to complaints survey combined with the standard survey, confirming ongoing noncompliance.

The facility failed to ensure medication labels were legible and expired medications were properly disposed of on medication carts and in medication storage rooms. Multiple observations revealed illegible or missing expiration dates on various medications, including expired vaccines and insulin without expiration labels. Staff interviews indicated inadequate training and inconsistent medication storage audits.

The facility failed to ensure medication labels were legible and that expired medications were disposed of after expiration date on six of six medication carts and in two of three medication storage rooms. Multiple medications had illegible or missing expiration dates, and expired vaccines were found and discarded. Staff training and audit processes were noted as inadequate.

The deficiencies resulted from the facility's noncompliance related to the standard survey with the complaints survey.

The facility failed to ensure medication labels were legible and expired medications were properly disposed of on multiple medication carts and storage rooms. Several medications had illegible or missing expiration dates, and expired vaccines were found and discarded. Staff training and audit processes were noted as inadequate.

The facility failed to ensure medication labels were legible and expired medications were properly disposed of on six medication carts and in two medication storage rooms. Multiple observations revealed illegible or missing expiration dates on various medications, including acetaminophen, naproxen, Humalog insulin, and expired vaccines. Staff interviews indicated inadequate training and inconsistent medication audits.

The revisit survey was related to complaints as indicated by the combination of standard survey with complaints survey.

The facility failed to ensure medication labels were legible and expired medications were properly disposed of on medication carts and in medication storage rooms. Multiple observations revealed illegible or missing expiration dates on various medications, including expired vaccines and insulin without expiration labels. Staff interviews indicated inadequate training and inconsistent medication storage audits.

The facility failed to ensure medication labels were legible and expired medications were properly disposed of on six medication carts and in two medication storage rooms. Multiple observations and interviews confirmed the presence of expired or illegibly labeled medications, including acetaminophen, naproxen, aspirin, Humalog insulin, and a pneumococcal vaccine. The Director of Nursing and Administrator acknowledged issues with medication storage audits and staff training.

The facility was found not in substantial compliance due to failure to properly seal penetrations in the mechanical room ceiling with approved fire caulk, affecting one of six smoke compartments. This deficiency was confirmed by staff during the inspection.

The facility was found deficient in multiple areas including medication management with expired and illegible medication labels, failure to assess a resident for self-administration of medications before leaving medications at bedside, incomplete care plans for residents with indwelling urinary catheters and oxygen therapy, and failure to conduct fingerprint criminal background checks for certain employees.

Multiple complaint intake numbers were investigated; several were unsubstantiated, some substantiated without deficiency, and one substantiated with deficiencies cited.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to assess resident for self-administration of medication, incomplete comprehensive care plans for residents with indwelling catheters and oxygen therapy, failure to update care plans for pressure injuries and discontinued oxygen therapy, oxygen administration not matching physician orders, and medication storage issues including expired and unlabeled medications.

The survey revealed deficiencies related to failure to conduct Georgia Criminal History Check System fingerprint checks for two Certified Nursing Assistants out of ten employee files reviewed.

Complaint Intake Numbers GA00231917, GA00240150, and GA00242362 were investigated. GA00231917 was substantiated with no deficiencies, GA00240150 was unsubstantiated, and GA00242362 was substantiated with deficiencies.

The facility was found to be in compliance with COVID-19 emergency preparedness and infection control regulations. However, deficiencies were identified related to failure to conduct required fingerprint background checks for two Certified Nursing Assistants (CNA BB and CNA CC).

The facility was found not in substantial compliance due to construction and repair operations related to a busted sprinkler pipe causing water damage and multiple openings in ceilings that were not properly sealed. This condition posed a risk of smoke spread to approximately 70 residents, and the facility was under continuous fire watch.

The facility was found deficient in multiple areas including misappropriation of resident property, medication management failures, lack of dental services, infection control deficiencies including COVID-19 signage and glove use during wound care, incomplete care plans for behaviors and bladder training, and malfunctioning call light system for a resident.

Complaint Intake Numbers GA00228902, GA00228505, and GA00227329 were investigated in conjunction with this standard survey and were unsubstantiated.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to treat residents with dignity, inadequate water temperatures, misappropriation of resident property, incomplete care plans for behaviors, failure to assess for bladder training, unsanitary oxygen equipment, lack of RN coverage for required hours, medication availability issues, inappropriate use of antipsychotic medication, medication administration errors, failure to obtain dental services, lack of COVID-19 outbreak signage, malfunctioning call light system, and ineffective pest control.

The facility failed to ensure a safe environment for one resident with a history of wrapping call lights, sheets, and curtains around her body, resulting in the resident's accidental death by hanging. The facility did not remove blind cords and failed to provide adequate supervision despite known risks.

Complaint intake #GA00217689 was substantiated with deficiencies related to the resident's death due to a window blind cord. Complaint intake #GA00218386 was substantiated without deficiencies.

The facility was found to be out of compliance with multiple regulatory requirements related to PASARR screening, comprehensive care planning, accident hazards and supervision, and behavioral health services. A resident was found deceased with a window blind cord wrapped around her neck, which was linked to inadequate supervision and failure to remove accident hazards. The facility implemented corrective actions including staff education, audits, and replacement of window blinds with cordless versions.

The survey investigated complaints GA00208496, GA00207649, GA00207232, and GA00207103. GA00207649 was substantiated with no deficiencies, while GA00208496, GA00207232, and GA00207103 were substantiated with deficiencies.

The facility was found not in compliance with infection control regulations related to COVID-19. Specifically, the facility failed to assign one resident who tested positive for COVID-19 to the designated COVID-19 unit until the resident met criteria for discontinuation of precautions, resulting in improper cohorting and potential infection control risk.

The facility failed to implement an effective infection prevention and control program including timely COVID-19 testing, proper screening of staff and visitors, adequate hand hygiene supplies, proper PPE use, and appropriate cohorting of residents. Immediate Jeopardy was identified due to these failures resulting in a COVID-19 outbreak with 101 residents and 40 staff testing positive and 27 resident deaths. The facility implemented corrective actions including staff education, screening protocols, PPE training, and cohorting guidance. The revisit validated removal of Immediate Jeopardy but the facility remains out of compliance and continues systematic changes.

The facility failed to timely retest rejected COVID-19 specimens, designate a single entrance for screening, maintain adequate hand hygiene supplies, ensure proper PPE use on the COVID-19 unit, and properly cohort and isolate newly admitted residents as Persons Under Investigation (PUIs). Additionally, the facility failed to notify residents and families timely about COVID-19 cases.

The facility was found not in substantial compliance with Life Safety Code requirements, specifically failing to protect hazardous areas with proper fire barriers and automatic closing doors, and failing to install smoke detectors in areas open to corridors without separation.

The facility was found deficient in pharmacy management due to failure to label insulin medications with open and expiration dates on two of seven medication carts. Additionally, the facility failed to provide rehabilitation equipment in a timely manner to one resident, resulting in delayed delivery of a prescribed foam cervical collar.

Complaint Intake Numbers GA00202022 and GA00197604 were substantiated with deficiencies related to the standard survey.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean environment due to dirty air filters in resident rooms, failure to involve a resident in care plan development, failure to provide timely rehabilitation equipment, improper labeling and storage of insulin medications, and multiple food safety violations including improper labeling, temperature control, and sanitation.

The facility was found not in substantial compliance due to failure to maintain multiple emergency lights at the 200 and 400 exterior and interior egress paths, which could place 30 residents and several staff at risk during a fire incident.